29-33: Patient Monitoring During Nutritional Support

Every patient receiving enteral or parenteral nutritional support should be monitored closely. Formal nutritional support teams composed of a physician, a nurse, a dietitian, and a pharmacist have been shown to decrease the rate of complications.

Patients should be monitored both for the adequacy of treatment and to prevent complications or detect them early when they occur. Because estimates of nutritional requirements are imprecise, frequent reassessment is necessary. Daily intakes should be recorded and compared with estimated requirements. Body weight, hydration status, and overall clinical status should be followed. Patients who do not appear to be responding as anticipated should have an indirect calorimetry study performed if possible and be evaluated for nitrogen balance by means of the following equation:

Patients who are receiving calorie prescriptions comparable to the results of the indirect calorimetry study and who have positive nitrogen balances can be continued on their current regimens, whereas patients not meeting their energy targets or who have negative nitrogen balances should receive moderate increases in calorie and protein, and then be reassessed. Monitoring for metabolic complications includes daily measurements of basic metabolic panels, magnesium, and phosphorus levels. Once the patient is stabilized on the goal nutritional support regimen, laboratory values can be checked 1–2 times per week. Patients on parenteral nutrition should receive weekly liver function tests and triglyceride levels. Vitamins and trace elements should be obtained every 3–6 months in patients receiving long-term nutritional support.